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Comparison of WHO and Indonesian growth standards in determining prevalence and determinants of stunting and underweight in children under five: a cross-sectional study from Musi sub-district

[version 1; peer review: 2 approved with reservations]

Flynn

Jeannie

Conceptualization Formal Analysis Investigation Project Administration Writing – Review & Editing https://orcid.org/0000-0001-7613-7095 1 Alkaff

Firas Farisi

Conceptualization Data Curation Formal Analysis Supervision Writing – Original Draft Preparation https://orcid.org/0000-0002-5628-1345 a 2 Sukmajaya

William Putera

Formal Analysis Methodology Writing – Original Draft Preparation 3 Salamah

Sovia

Formal Analysis Methodology Writing – Review & Editing 4 1Oeolo Primary Healthcare, Jln. Tetu Neno, Timor Tengah Utara District, East Nusa Tenggara Province, 85662, Indonesia 2Department of Pharmacology, Faculty of Medicine, Faculty of Medicine Universitas Airlangga, Jl. Mayjend Prof. Dr. Moestopo No 47, Surabaya, East Java, 60132, Indonesia 3Department of Orthopedics and Traumatology, Faculty of Medicine, Faculty of Medicine Brawijaya University, Jl. Jaksa Agung Suprapto No 2, Malang, East Java, 65111, Indonesia 4Department of Public Health and Preventive Medicine, Faculty of Medicine, Faculty of Medicine Universitas Airlangga, Jl. Mayjend Prof. Dr. Moestopo No 47, Surabaya, East Java, 60132, Indonesia

a firasfarisialkaff@fk.unair.ac.id

*Equal contributors

No competing interests were disclosed.

4 5 2020

2020

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23 4 2020

2020

This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Undernutrition among children under five continues to be a critical global public health challenge, especially in developing countries. However, it is believed that Indonesian children are “below” the global standard, thus the WHO standard is not reliable to present the actual prevalence. This study aims to compare the difference between WHO and Indonesian growth standards regarding prevalence of stunting and underweight and its determinants.

Methods: This is a cross-sectional study carried out in Musi sub-district, East Nusa Tenggara province in July 2019. East Nusa Tenggara province had the highest prevalence of stunting and underweight in Indonesia. The study population were children under five, and total sampling method was used for this study. Length/height-for-age and weight-for-age were plotted using WHO and national standards. Univariate and multivariate binomial logistic regression were used for statistical analysis.

Results: The prevalence of stunting and underweight were higher for the WHO than the national standard (53.9% vs 10.7% and 29.17% vs 17.7%; all p < 0.001). Determinants of stunting were maternal mid-upper arm circumference below 23.5cm and maternal height below 150cm when the WHO standard was used, and no determinant was found when the national standard was used. Determinants of underweight were intrauterine growth restriction, young maternal age during pregnancy, and multiple parities when the WHO standard was used. When the national standard was used, the determinants of underweight were intrauterine growth restriction and maternal education.

Conclusions: The WHO standard over-diagnosed stunting and underweight in Musi sub-district. Future studies should be done to re-evaluate the prevalence and determinants of stunting and underweight nationwide using the Indonesian standard.

growth chart Indonesia risk factors stunting underweight

The author(s) declared that no grants were involved in supporting this work.

Introduction

Undernutrition among children under five continues to be a critical global public health challenge, especially in developing countries ¹. Not only affecting the health of one individual, undernutrition also contributes to many aspects of sustainable development ². There are three indicators to measure nutritional imbalance that lead to undernutrition, which are: stunting (low height for age), underweight (low weight for age), and wasting (low weight for height). Stunting is the result of chronic nutritional deprivation, reflecting the cumulative effects of undernutrition and infection. Underweight is a composite indicator and it includes both acute and chronic undernutrition. Wasting is a symptom of acute undernutrition, usually caused by insufficient food intake or high incidence of infectious disease. High prevalence of those indicators reflects poor nutrition and health status among children under five in the population ³.

According to the data from 2011, the global incidence of stunting, underweight, and wasting were approximately 164.8 million (25.7%), 100.7 million (15.7%), and 51.5 million (8%) among children under five, respectively. Meanwhile, the global deaths attributed to stunting, underweight, and wasting were approximately 1.017 million (14.7%), 999,000 (14.4%), and 875,000 (12.6%) ⁴. Until 2018, undernutrition rates remained alarming, although the prevalence was declining. Among continents, Asia has the highest prevalence of stunting (55%) and wasting (68%). Based on country income classification, 65% of all stunted and 73% of all wasted children live in lower- and middle-income countries ⁵. However, in the 2018 report, there is no updated data regarding the prevalence of underweight.

The latest basic health survey in Indonesia in 2018 showed that the prevalence of stunting, underweight, and wasting was 30.8%, 17.7%, and 10.2%, respectively. Among other provinces in Indonesia, East Nusa Tenggara province has the highest prevalence of stunting and underweight, at 42.6% and 29.5%, respectively. Meanwhile, the prevalence of wasting was lower, ranked 8 ^th out of 35 provinces ⁶. According to undernutrition severity classification, the severity of stunting is high and underweight is medium in Indonesia. In East Nusa Tenggara province, the severity of stunting is very high, and the severity of underweight is high ⁷.

The determinants of child undernutrition are multifaceted and interconnected ⁸. Understanding the determinants of childhood undernutrition is important to improve children’s nutrition by developing the effective and sustained multi-sectorial nutrition programs and interventions over the long term ⁹. Unfortunately, studies evaluating the risk factors of child malnutrition in Indonesia were scarce ¹⁰. A recent review article showed that determinants of stunting in Indonesia were similar to other countries, including maternal height and education, premature birth and birth length, exclusive breastfeeding, and socioeconomic status ¹¹.

However, determination of undernutrition always uses the WHO growth standard in Indonesia. It is believed that Indonesian children are “below” the global standard in general, thus the WHO standard is not reliable to present the actual prevalence. Therefore, the Indonesia national growth standard was made using data from National Basic Health Survey ¹². To this date, no study has been done to scrutinize the difference between these two standards. This study aims to compare the prevalence and determinants of stunting and underweight using WHO and national standards. We use the data from one of the sub-districts in East Nusa Tenggara province because this province had the highest prevalence of stunting and underweight among children under five in Indonesia.

Methods Ethical statement

This study followed the principles of the Declaration of Helsinki and was approved by the Department of Health Timor Tengah Utara district (approval number: DINKES.440/995/XI/2019). This study also complies with STROBE guidelines ^{13,
14}. All parents gave their written informed consent prior to their children’s inclusion in the study. Information for informed consent was given before the informed consent form was signed. Details that might disclose the identity of the study subjects were omitted from the published data file.

Study design and population

This study was an observational cross-sectional study conducted in Musi sub-district, one of the sub-districts in East Nusa Tenggara province. Participant recruitment and data collection were conducted in July 2019. Data analysis was conducted in October – December 2019. There were six villages in Musi sub-district. The study population were children aged less than five years old. Total sampling was used for this study. The children and their parents were approached face-to-face by JF during the monthly growth monitoring program in Posyandu (“Pos Pelayanan Terpadu”), a healthcare program by the Indonesian government. Inclusion criteria were children under five who attended the growth monitoring program during the study period, who were born and live with their parents in Musi sub-district, and had both maternal and child health books ( Buku Kesehatan Ibu dan Anak / KIA) and health record card ( Kartu Menuju Sehat / KMS) published by the Ministry of Health Republic Indonesia. Children with incomplete KIA and KMS were excluded from the determinants analysis.

Data collection

Both primary and secondary data was used in this study. Primary data for this study consisted of data obtained through interviews with parents, child anthropometry measurements, and maternal height measurements. The interviews took place in the same location as the Posyandu and were conducted by JF using a predetermined questionnaire. The length of the interview was around five minutes. JF is a female general practitioner who worked in primary healthcare in the sub-district where the study took place. She had worked there for seven months when the study was conducted. Interviews with parents was carried out to obtain information regarding village of origin, parents’ highest education, number of parities, delivery method, and gender and age of their children. Anthropometry measurements of maternal height and child length/height were done by healthcare workers from Oeolo Primary Healthcare. Secondary data from KIA and KMS was used to obtain data regarding birthweight, gestational age, maternal mid-upper arm circumference, and maternal age during pregnancy.

Categorization of variables

Underweight and stunting were categorized using WHO child growth standards and Indonesian growth standards for the same sex ^{12,
15}. Underweight is defined as weight for age below -2 standard deviations (SD), and severe underweight is defined as weight for age below -3 SD. Stunting is defined as length/height for age below -2 SD, and severe stunting is defined as length/height for age below -3 SD. The cut-off level for maternal mid-upper arm circumference was 23.5 cm, for maternal height was 150 cm, and for children’s birthweight was 2500 g. The cut-off level for maternal mid-upper arm circumference was according to the Indonesian national cut-off ¹⁶, while for maternal height and children’s birthweight, the cut-off was based on a previous study ¹⁷. Maternal age during pregnancy was categorized to <20 years old, 20–35 years old, and >35 years old. Gestational age and intrauterine growth were categorized based on Lubchenco charts. It categorizes the gestational age to preterm (<37 weeks), term (37–42 weeks), or postterm (>42 weeks) and the intrauterine growth to small for gestational age (SGA) (<10 ^th percentile), appropriate for gestational age (AGA) (10 ^th – 90 ^th percentile), or large for gestational age (LGA) (>90 ^th percentile) ¹⁸.

Statistical analysis

Acquired data was analysed using SPSS Statistic for Windows, version 25.0 (IBM Corp., Armonk, N.Y., USA). Data analysis was conducted in two phases. In the first phase, univariate logistic regression was used to identify independent variables that were associated with stunting or underweight. Variables with p < 0.1 were included in the next phase. In second phase, multivariate logistic regression using backward selection was used. Variables with p <0.05 from multivariate analysis were considered as the determinants.

Results

There was a total of 408 children under five in Musi sub-district. Based on WHO standard, the prevalence of stunting and underweight were 53.9% and 29.17%, respectively ^{19,
20}. Using national standard, the prevalence of stunting and underweight were 10.7% and 17.7%, respectively. There was a significant difference of stunting and underweight between the prevalence from the WHO and national standard (both p <0.001). However, there were only 218 children that fulfilled the criteria to be included for the determinants analysis ( Table 1).

Table 1. Prevalence of stunting and underweight of children aged 0 – 59 months in Musi sub-district.

Variable	Total prevalence (N = 408) n (%)		p-value	Study participants (N = 218) n (%)		p-value
Variable	WHO	National	p-value	WHO	National	p-value
Stunting (length/height for age index) Normal (-2 SD and above) Stunted (<-2 SD to ≤-3 SD) Severely stunted (<-3 SD)	188(46.1) 148(36.3) 72(17.6)	364(89.22) 41(10.05) 3(0.73)	< 0.001 *	106(48.6) 75(34.4) 37(17)	200(91.7) 17(7.8) 1(0.5)	< 0.001 *
Underweight (weight for age index) Normal (-2 SD and above) Underweight (<-2 SD to ≤-3 SD) Severely underweight (<-3SD)	289(70.83) 96 (23.53) 23 (5.64)	336(82.3) 57(14) 15(3.7)	< 0.001 ^#	149(68.3) 55(25.3) 14(6.4)	176(80.7) 33(15.2) 9(4.1)	< 0.001 ^#

Chi square test was used.

*p-value between stunted (and severely stunted) and normal.

^#p-value between underweight (and severely underweight) and normal.

p <0.05 was considered statistically significant.

Sociodemographic characteristics

The prevalence of stunting and underweight among this study population were 51.4% and 31.7% according to WHO standard and 8.3% and 19.3% according to national standard ( Table 1). The number of male and female children was almost equal. More than half of the children were aged between 24 and 59 months old. Majority of the children were born term with a birthweight of more than 2500 g. The education level of both parents was mainly elementary school graduates. Almost half of the mothers had a height of less than 150 cm and more than half of the mothers had a mid-arm circumference of ≤23.5 cm during pregnancy ( Table 2).

Table 2. Sociodemographic characteristics among children aged 0–59 months in Musi Sub-district.

Characteristic	Total		WHO		National
	(N = 218)		Stunted	Underweight	Stunted	Underweight
	n	%	%	%	%	%
Infant
Child’s gender Male Female	108 110	49.5 50.5	52.8 50	30.6 32.7	7.4 9.1	16.7 21.8
Child’s age group 0–23 months 24–59 months	98 120	45 55	45.9 55.8	29.6 33.3	9.2 7.5	17.3 20.8
Child’s birthweight <2500 g ≥2500 g	35 183	16.1 83.9	65.7 48.6	54.3 27.3	17.1 6.6	40 15.3
Intrauterine growth SGA AGA LGA	38 174 6	17.4 79.8 2.8	65.8 48.9 33.3	57.9 27 0	15.8 6.9 0	44.7 14.4 0
Gestational age Preterm Term Postterm	13 204 1	6 93.6 0.4	61.5 51 0	30.8 31.9 0	15.4 7.8 0	23.1 19.1 0
Parents
Paternal education No formal education Primary school graduates Secondary school graduates High secondary school graduates University graduates	6 126 32 42 12	2.8 57.8 14.7 19.3 5.5	83.3 54.8 50 45.2 25	50 31.7 28.1 38.1 8.3	33.3 9.5 6.3 4.8 0	50 22.2 15.6 14.3 0
Maternal education No formal education Primary school graduates Secondary school graduates High secondary school graduates University graduates	4 103 35 48 28	1.8 47.2 16.1 22 12.8	75 52.4 65.7 47.9 32.1	75 29.1 40 35.4 17.9	25 8.7 8.6 10.4 0	75 20.4 22.9 18.8 3.6
Maternal MUAC ≤23.5 cm >23.5 cm	125 93	57.3 42.7	43.2 44.1	31.2 32.3	10.4 5.4	22.4 15.1
Maternal height <150 cm ≥150 cm	96 122	44 56	65.6 40.2	40.6 24.6	12.5 4.9	26 13.9
Maternal age during pregnancy <20 years old 20–35 years old >35 years old	20 166 32	9.2 76.1 14.7	70 50.6 43.8	65 25.9 40.6	15 8.4 3.1	40 15.7 25
Number of parities 1 2 3 4 >4	51 65 51 30 21	23.4 29.8 23.4 13.8 9.6	56.9 43.1 60.8 36.7 61.9	35.3 24.6 37.3 16.7 52.4	9.8 7.7 9.8 0 14.3	19.6 18.5 27.5 3.3 23.8

SGA, small for gestational age; AGA, appropriate for gestational age; LGA, large for gestational age; MUAC, mid-upper arm circumference.

Determinants of stunting according to WHO and national standards

Based on WHO standard, univariate logistic regression analysis indicated that children with maternal height below 150 cm (OR = 2.844; 95% CI = 1.632 – 4.956) were more likely to be stunted ( Table 3). In the multivariate logistic regression analysis, other variables with p-value between 0.05 and 0.1 from the univariate analysis (child’s birthweight, child’s intrauterine growth status, maternal mid-upper arm circumference, and number of parities) were included. Multivariate analysis indicated that children with maternal height below 150 cm (OR = 2.936; 95% CI = 1.672 – 5.154) or maternal mid-upper arm circumference below 23.5 cm (OR = 1.796; 95% CI = 1.008 – 3.105) were more likely to be stunted ( Table 4).

Table 3. Univariate analysis of determinants for stunting among children aged 0–59 months in Musi Sub-district.

Variables	WHO			National
Variables	OR	95% CI	p value	OR	95% CI	p value
Infant factors
Child’s gender Male Female (ref)	1.118 -	[0.657 – 1.902] -	0.682 -	0.8 -	[0.303 – 2.111] -	0.652 -
Child’s age group 0–23 months 24–59 months (ref)	0.672 -	[0.393 – 1.148] -	0.146 -	1.247 -	[0.475 – 3.274] -	0.654 -
Child’s birthweight <2500 g ≥2500 g (ref)	2.024 -	[0.951 – 4.310] -	0.067 -	2.948 -	[1.025 – 8.476] -	0.045 -
Intrauterine growth SGA AGA (ref) LGA	2.014 - 0.524	[0.967 – 4.192] - [0.093 – 2.933]	0.061 - 0.462	2.531 - 0.0	[0.885 – 7.239] - [0]	0.083 - 0.999
Gestational age Preterm Term (ref) Postterm	1.538 - 0.0	[0.487 – 4.862] - [0]	0.463 - 1.0	2.136 - 0.0	[0.435 – 10.484] - [0]	0.350 - 1.0
Parent factors
Paternal education No formal education Primary school graduates Secondary school graduates High secondary school graduates (ref) University graduates	6.053 1.465 1.211 - 0.404	[0.65 – 56.365] [0.727 – 2.956] [0.482 – 3.042] - [0.096 – 1.705]	0.114 0.286 0.685 - 0.217	10 2.105 1.333 - 0.0	[1.094 – 91.441] [0.451 – 9.817] [0.178 – 10.014] - [0]	0.041 0.343 0.780 - 0.999
Maternal education No formal education Primary school graduates Secondary school graduates High secondary school graduates (ref) University graduates	3.261 1.198 2.083 - 0.515	[0.316 – 33.614] [0.603 – 2.378] [0.848 – 5.118] - [0.194 – 1.364]	0.321 0.606 0.109 - 0.182	2.867 0.823 0.806 - 0.0	[0.249 – 33.065] [0.260 – 2.604] [0.179 – 3.623] - [0]	0.399 0.741 0.779 - 0.998
Maternal MUAC ≤23.5 cm >23.5 cm (ref)	1.668 -	[0.971 – 2.865] -	0.064 -	2.043 -	[0.702 – 5.947] -	0.190 -
Maternal height <150 cm ≥150 cm (ref)	2.844 -	[1.632 – 4.956] -	< 0.001 -	2.762 -	[0.997 – 7.655] -	0.051 -
Maternal age during pregnancy <20 years old 20–35 years old (ref) >35 years old	2.278 - 0.759	[0.835 – 6.214] - [0.354 – 1.626]	0.108 - 0.479	1.916 - 0.350	[0.500 – 7.346] - [0.044 – 2.762]	0.343 - 0.319
Number of parities 1 (ref) 2 3 4 >4	- 0.574 1.176 0.439 1.233	- [0.274 – 1.204] [0.534 – 2.589] [0.174 – 1.109] [0.435 – 3.490]	- 0.142 0.687 0.082 0.693	- 0.767 1.0 0.0 1.533	- [0.209 – 2.807] [0.271 – 3.689] [0] [0.332 – 7.092]	- 0.688 1.0 0.998 0.584

SGA, small for gestational age; AGA, appropriate for gestational age; LGA, large for gestational age; MUAC, mid-upper arm circumference.

Table 4. Multivariate analysis of determinants for stunting among children aged 0–59 months in Musi Sub-district.

Variables	WHO			National
Variables	OR	95% CI	p value	OR	95% CI	p value
Infant factors
Child’s gender Male Female (ref)
Child’s age group 0–23 months 24–59 months (ref)
Child’s birthweight <2500 g ≥2500 g (ref)
Intrauterine growth SGA AGA (ref) LGA
Gestational age Preterm Term (ref) Postterm
Parent factors
Paternal education No formal education Primary school graduates Secondary school graduates High secondary school graduates (ref) University graduates
Maternal education No formal education Primary school graduates Secondary school graduates High secondary school graduates (ref) University graduates
Maternal MUAC ≤23.5 cm >23.5 cm (ref)
Maternal height <150 cm ≥150 cm (ref)	1.769 -	[1.008 – 3.105] -	0.047 -
Maternal age during pregnancy <20 years old 20–35 years old (ref) >35 years old	2.936 -	[1.672 – 5.154] -	<0.001 -
Number of parities 1 (ref) 2 3 4 >4

SGA, small for gestational age; AGA, appropriate for gestational age; LGA, large for gestational age; MUAC, mid-upper arm circumference.

Based on national standard, univariate logistic regression analysis indicated that children with birthweight below 2500 g (OR = 2.948; 95% CI = 1.025 – 8.476) or with a father without formal education (OR = 10; 95% CI = 1.094 – 91.441) were more likely to be stunted ( Table 3). In multivariate logistic regression analysis, other variables with p-value between 0.05 and 0.1 from the univariate analysis (child’s intrauterine growth status and maternal height) were included. No determinant was found in the multivariate analysis ( Table 4).

Determinants of underweight according to WHO and national standards

Based on WHO standard, univariate logistic regression analysis indicated that children with a birthweight below 2500 g (OR = 3.159; 95% CI = 1.507 – 6.622) or intrauterine growth restriction (OR = 3.715; 95% CI = 1.798 – 7.677) were more likely to be underweight. Children with maternal height below 150 cm (OR = 2.098; 95% CI = 1.176 – 3.745) or maternal age under 20 years old during pregnancy (OR = 5.312; 95% CI = 1.989 – 14.186) were also more likely to be underweight ( Table 5). In multivariate logistic regression analysis, other variables with p-value between 0.05 and 0.1 from the univariate analysis (paternal education and number of parities) were included. Multivariate analysis indicated that children with intrauterine growth restriction (OR = 3.182; 95% CI = 1.450 – 6.980) were more likely to be underweight. Children with maternal age under 20 years old during pregnancy (OR = 6.252; 95% CI = 1.911 – 20.457) or with mother that had more than four parities (OR = 4.319; 95% CI = 1.189 – 15.689) were also more likely to be underweight ( Table 6).

Table 5. Univariate analysis of determinants for underweight among children aged 0–59 months in Musi Sub-district.

Variables	WHO			National
Variables	OR	95% CI	p value	OR	95% CI	p value
Infant factors
Child’s gender Male Female (ref)	0.904 -	[0.511 – 1.601] -	0.730 -	0.717 -	[0.363 – 1.413] -	0.336 -
Child’s age group 0–23 months 24–59 months (ref)	0.841 -	[0.472 – 1.496] -	0.555 -	0.798 -	[0.403 – 1.580] -	0.517 -
Child’s birthweight <2500 g ≥2500 g (ref)	3.159 -	[1.507 – 6.622] -	0.002 -	3.690 -	[1.680 – 8.107] -	0.001 -
Intrauterine growth SGA AGA (ref) LGA	3.715 - 0.0	[1.798 – 7.677] - [0]	< 0.001 - 0.999	4.825 - 0.0	[2.241 – 10.389] - [0]	< 0.001 - 0.999
Gestational age Preterm Term (ref) Postterm	0.950 - 0.0	[0.282 – 3.200] - [0]	0.935 - 1.0	1.269 - 0.0	[0.333 – 4.831] - [0]	0.727 - 1.0
Parent factors
Paternal education No formal education Primary school graduates Secondary school graduates High secondary school graduates (ref) University graduates	1.625 0.756 0.636 - 0.148	[0.292 – 9.050] [0.365 – 1.564] [0.236 – 1.713] - [0.017 – 1.255]	0.579 0.450 0.370 - 0.080	6.0 1.714 1.111 - 0	[0.973 – 36.986] [0.656 – 4.481] [0.307 – 4.026] - [0]	0.054 0.272 0.873 - 0.999
Maternal education No formal education Primary school graduates Secondary school graduates High secondary school graduates (ref) University graduates	5.474 0.749 1.216 - 0.396	[0.527 – 56.714] [0.362 – 1.553] [0.495 – 2.985] - [0.128 – 1.232]	0.154 0.438 0.670 - 0.110	13.0 1.110 1.284 - 0.160	[1.207 –139.959] [0.465 – 2.646] [0.440 – 3.748] - [0.019 – 1.342]	0.034 0.814 0.647 - 0.091
Maternal MUAC ≤23.5 cm >23.5 cm (ref)	0.952 -	[0.535 – 1.695] -	0.868 -	1.629 -	[0.803 – 3.303] -	0.176 -
Maternal height <150 cm ≥150 cm (ref)	2.098 -	[1.176 – 3.745] -	0.012 -	2.175 -	[1.095 – 4.318] -	0.026 -
Maternal age during pregnancy <20 years old 20–35 years old (ref) >35 years old	5.312 - 1.957	[1.989 – 14.186] - [0.892 – 4.296]	0.001 - 0.094	3.590 - 1.795	[1.337 – 9.638] - [0.728 – 4.428]	0.011 - 0.204
Number of parities 1 (ref) 2 3 4 >4	- 0.599 1.089 0.367 2.017	- [0.274 – 1.204] [0.534 – 2.589] [0.174 – 1.109] [0.435 – 3.490]	- 0.212 0.837 0.079 0.182	- 0.928 0.1551 0.141 1.281	- [0.365 – 2.360] [0.615 – 3.913] [0.017 – 1.166] [0.379 – 4.336]	- 0.876 0.352 0.069 0.690

SGA, small for gestational age; AGA, appropriate for gestational age; LGA, large for gestational age; MUAC, mid-upper arm circumference.

Table 6. Multivariate analysis of determinants for underweight among children aged 0–59 months in Musi Sub-district.

Variables	WHO			National
Variables	OR	95% CI	p value	OR	95% CI	p value
Infant factors
Child’s gender Male Female (ref)
Child’s age group 0–23 months 24–59 months (ref)
Child’s birthweight <2500 g ≥2500 g (ref)
Intrauterine growth SGA AGA (ref) LGA	3.182 - 0.0	[1.450 – 6.980] - [0]	0.004 0.999	4.191 - 0.0	[1.820 – 9.649] - [0]	0.001 - 0.999
Gestational age Preterm Term (ref) Postterm
Parent factors
Paternal education No formal education Primary school graduates Secondary school graduates High secondary school graduates (ref) University graduates
Maternal education No formal education Primary school graduates Secondary school graduates High secondary school graduates (ref) University graduates				27.341 1.147 1.409 - 0.193	[1.281 - 583.318] [0.412 – 3.188] [0.444 – 4.468] - [0.022 – 1.674]	0.034 0.793 0.561 - 0.136
Maternal MUAC ≤23.5 cm >23.5 cm (ref)
Maternal height <150 cm ≥150 cm (ref)
Maternal age during pregnancy <20 years old 20–35 years old (ref) >35 years old	6.252 - 1.449	[1.911 – 20.467] [0.565 – 3.718]	0.002 - 0.441
Number of parities 1 (ref) 2 3 4 >4	- 1.283 2.601 0.827 4.319	- [0.480 – 3.430] [0.938 – 7.210] [0.220 – 3.101] [1.189 – 15.689]	- 0.619 0.066 0.778 0.026

SGA, small for gestational age; AGA, appropriate for gestational age; LGA, large for gestational age; MUAC, mid-upper arm circumference.

Based on national standard, univariate logistic regression analysis indicated that children with birthweight below 2500 g (OR = 3.690; 95% CI = 1.680 – 8.107) or intrauterine growth restriction (OR = 4.825; 95% CI = 2.241 – 10.389) were more likely to be underweight. Children with mother without formal education (OR = 13.95%; CI = 1.207 – 139,959), with height below 150 cm (OR = 2.175; 95% CI = 1.095 – 4.318), or aged under 20 years old during pregnancy (OR = 3.590; 95% CI = 0.011) were also more likely to be underweight ( Table 5). In multivariate logistic regression analysis, other variables with p-value between 0.05 and 0.1 from the univariate analysis (paternal education and number of parities) were included. Multivariate analysis indicated that children with intrauterine growth restriction (OR = 4.191; 95% CI = 1.820 – 9.649) were more likely to be underweight. Children with mother without formal education (OR = 27.341; 95% CI =1.281 – 583,318) were also more likely to be underweight ( Table 6).

Discussion

In our study, the prevalence of both stunting and underweight were significantly lower when measured using Indonesian standard compared to when using WHO standard. It has been suggested that overdiagnoses of stunting or underweight are more likely to occur in developing countries ²¹. There are many countries that already proposed their own national growth standard, which are: Korea ²², Thailand ²³, Argentina ²⁴, China ²⁵, India ²¹, and 18 European countries ²⁶. It is argued that the national growth standard of each country is more suitable to reflect the condition in its own population ²³. However, there were only few published studies that compare the difference between national growth standards and WHO growth standard. A comparison study among Thai children in the first two years of life showed that the prevalence of stunting was higher when using WHO standard in both sexes, but at 24 months the only significant difference was in girls. The prevalence of underweight showed a monotonic increment when using WHO standard, but the Thailand national standard showed a fluctuation ²³. In Argentina, the prevalence of underweight using WHO standard was 2 times higher than when using their national standard. Meanwhile for stunting, the prevalence when using WHO standard was 1.5 times higher ²⁴. In contrary, a comparison study from China showed that the prevalence of stunting and underweight was significantly higher when measured using their national standard ²⁵.

The marked difference in measurements using Indonesian standard and WHO standard probably stems from the difference in methodology during the development of both growth reference standards. The WHO standard was developed using data from five cities in five different countries: United States, Turkey, Norway, Brazil, and India. The children included in the study were healthy children with suitable sociodemographic conditions for growth. Moreover, all participants agreed to follow the feeding recommendation by WHO ²⁷. In contrary, the development of Indonesian standard did not have any inclusion and exclusion criteria for study participants. It also did not mention the sociodemographic background of the participants or their feeding habits. The study, however, collected data from all 33 provinces of Indonesia to better reflect the growth of Indonesian children ¹².

Review article by Beal et al. concluded that the determinants of stunting in Indonesia are maternal height and education, child’s gender, premature birth and birth length, exclusive breastfeeding for six months, living area, and household socio-economic status ¹¹. In our study, the determinants of stunting according to WHO standard were maternal height less than 150 cm and maternal upper mid-arm circumference <23.5 cm. In contrast, no determinant was found when Indonesian standard was used. It is because the prevalence of stunting according to Indonesian standard was low. The significant difference in stunting prevalence calculated using Indonesian and WHO standards might be because the WHO standard does not represent local growth appropriately due to population differences in height ²⁶, and Indonesian people are generally shorter than the rest of the world.

Regarding underweight, the determinants were also different according to the two different standards. However, there was one common determinant: intrauterine growth restriction. The difference of underweight prevalence between the two standards was not as marked as the difference in stunting prevalence; this may explain that there was still one overlapping determinant. The increased odds of undernutrition in SGA infants are more relevant in low- and middle-income countries ²⁸. SGA children are born with lower intrinsic potential for growth due to the persistent effect of growth restriction in utero ^{29,
30}. SGA is a result of poor maternal nutrition during pregnancy when the child is totally dependent on getting nutrition from the mother through the placenta, hence any nutrition deprivation from the mother will affect the proper growth and development of the fetus ³¹.

There were several limitations of this study. We did not discern the feeding habits of the participants of this study. Feeding habit could be an important determinant of malnutrition. For example, introduction of complimentary food earlier than four months increased the likelihood of being underweight and stunted ³². Data on exclusive breastfeeding and history of immunization cannot be obtained because some of our samples have not yet completed the exclusive breastfeeding and basic immunization period. Data regarding socioeconomic status could not be obtained due to parents’ unstable monthly income. Data regarding the frequency of diarrhea could not be obtained because this was not well documented in primary healthcare medical records. These factors should be accounted for in the ensuing studies. Nevertheless, to our despite all of the limitations, this is the first study that compare the prevalence and determinants of stunting and underweight among Indonesian children under five using Indonesian growth standard and WHO growth standard.

Conclusion

The WHO standard was not suitable to diagnose stunting and underweight in Musi sub-district, since the prevalence was significantly higher when using WHO standard compared to when using Indonesian standard. Future studies should be done to re-evaluate the prevalence and determinants of stunting and underweight nationwide using the Indonesian standard. An Indonesian standard for weight-for-height should also be made to re-evaluate the prevalence and determinants of wasting in Indonesia.

Data availability Underlying data

Figshare: Growth standard comparison between WHO and Indonesian Growth Chart-Population Data. https://doi.org/10.6084/m9.figshare.12121938.v5 ¹⁹

Figshare: Growth standard comparison between WHO and Indonesian Growth Chart-Determinants Data. https://doi.org/10.6084/m9.figshare.12127425.v3 ²⁰

Reporting guidelines

Figshare: STROBE Checklist-Indonesian and WHO Growth Standard Comparison. https://doi.org/10.6084/m9.figshare.12127689.v2 ¹³

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgements

The authors thank Dr. Aman Bhakti Pulungan for providing the chart of Indonesian National Growth Standard and to Oeolo primary healthcare workers for their assistance during data collection.

Gebre

Reddy

Mulugeta

: Prevalence of Malnutrition and Associated Factors among Under-Five Children in Pastoral Communities of Afar Regional State, Northeast Ethiopia: A Community-Based Cross-Sectional Study. J Nutr Metab. 2019;2019:9187609. 31275645

10.1155/2019/9187609

6589243

International Food Policy Research Institute: Global Nutrition Report 2015: Actions and Accountability to Advance Nutrition and Sustainable Development. Washington, DC;2015;168. Reference Source

World Health Organization: Nutrition Landscape Information System (NLIS) Country Profile Indicators: Interpretation Guide. Geneva: WHO;2010. Reference Source

Black

Victora

Walker

: Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427–51. 23746772

10.1016/S0140-6736(13)60937-X

United Nations Children’s Fund (UNICEF): World Health Organization, International Bank for Reconstruction and Development/The World Bank: Levels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates.Geneva: World Health Organization;2019. Reference Source

Badan Penelitian dan Pengembangan Kementerian Kesehatan Republik Indonesia. Hasil Utama RISKESDAS 2018 . Jakarta: Kemenkes RI;2018. Reference Source

World Health Organization: Global Database on Child Growth and Malnutrition. [cited 9 February 2020]. Reference Source

Boah

Azupogo

Amporfro

: The epidemiology of undernutrition and its determinants in children under five years in Ghana. PLoS One. 2019;14(7):e0219665. 31365528

10.1371/journal.pone.0219665

6668784

Khan

Zaheer

Safdar

: Determinants of stunting, underweight and wasting among children < 5 years of age: evidence from 2012-2013 Pakistan demographic and health survey. BMC Public Health. 2019;19(1):358. 30935382

10.1186/s12889-019-6688-2

6444880

Sumarto

De Silva

: Child Malnutrition in Indonesia: Can Education, Sanitation and Healthcare Augment the Role of Income? TNP2K Working Paper 31-2015. Jakarta, Indonesia: Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K);2015. Reference Source

Beal

Tumilowicz

Sutrisna

: A review of child stunting determinants in Indonesia. Matern Child Nutr. 2018;14(4):e12617. 29770565

10.1111/mcn.12617

6175423

Pulungan

Julia

Batubara

JRL

: Indonesian National Synthetic Growth Charts. Acta Scientific Paediatrics. 2018;1:20–34. Reference Source

Flynn

Alkaff

Sukmajaya

: STROBE Checklist-Indonesian and WHO Growth Standard Comparison. figshare. Online resource.2020. http://www.doi.org/10.6084/m9.figshare.12127689.v2

von Elm

Altman

Egger

: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Bull World Health Organ. 2007;85(11):867–872. 18038077

10.2471/blt.07.045120

2636253

World Health Organization: Training Course on Child Growth Assessment. Geneva: WHO;2008. Reference Source

Indonesian Minister of Health Decree Number 97/2014 on Health Care Before Pregnancy, During Pregnancy, During Labor, and After Labor, Implementation of Contraception Services, and Sexual Health Services.Jakarta;2014.

Berhe

Seid

Gebremariam

: Risk factors of stunting (chronic undernutrition) of children aged 6 to 24 months in Mekelle City, Tigray Region, North Ethiopia: An unmatched case-control study. PLoS One. 2019;14(6):e0217736. 31181094

10.1371/journal.pone.0217736

6557492

Lubchenco

Hansman

Dressler

: Intrauterine Growth As Estimated From Liveborn Birth-Weight Data At 24 To 42 Weeks Of Gestation. Pediatrics. 1963;32:793–800. 14075621

Flynn

Alkaff

Sukmajaya

: Growth standard comparison between WHO and Indonesian Growth Chart-Population Data. figshare. Dataset. http://www.doi.org/10.6084/m9.figshare.12121938.v5

Flynn

Alkaff

Sukmajaya

: Growth standard comparison between WHO and Indonesian Growth Chart-Determinants Data. figshare. Dataset.2020. http://www.doi.org/10.6084/m9.figshare.12127425.v3

Khadilkar

: Growth charts: A diagnostic tool. Indian J Endocrinol Metab. 2011;15(Suppl 3):S166–71. 22029020

10.4103/2230-8210.84854

3183514

Kim

Yun

Hwang

: The 2017 Korean National Growth Charts for children and adolescents: development, improvement, and prospects. Korean J Pediatr. 2018;61(5):135–49. 29853938

10.3345/kjp.2018.61.5.135

5976563

Hong

Mongkolchati

Chompikul

: Comparison of Prevalence of Nutritional Status of Thai Children in the First 2 Years of Life Using National and International Growth Charts. J Med Assoc Thai. 2016;99(1):58–64. 27455825

Padula

Seoane

Salceda

: Variations in estimates of underweight, stunting, wasting, overweight and obesity in children from Argentina comparing three growth charts. Public Health Nutr. 2012;15(11):2086–90. 22444072

10.1017/S136898001200095X

Yang

Duan

: Comparison of the China growth charts with the WHO growth standards in assessing malnutrition of children. BMJ Open. 2015;5(2):e006107. 25716173

10.1136/bmjopen-2014-006107

4342594

Bonthuis

van Stralen

Verrina

: Use of national and international growth charts for studying height in European children: development of up-to-date European height-for-age charts. PLoS One. 2012;7(8):e42506. 22916131

10.1371/journal.pone.0042506

3419735

World Health OrganizationUnited Nations Children's Fund. WHO child growth standards and the identification of severe acute malnutrition in infants and children: A Joint Statement. Geneva: World Health Organization and UNICEF;2009;11. 24809116

Christian

Lee

Donahue Angel

: Risk of childhood undernutrition related to small-for-gestational age and preterm birth in low- and middle-income countries. Int J Epidemiol. 2013;42(5):1340–55. 23920141

10.1093/ije/dyt109

3816349

Blake

Park

Baltazar

: LBW and SGA Impact Longitudinal Growth and Nutritional Status of Filipino Infants. PLoS One. 2016;11(7):e0159461. 27441564

10.1371/journal.pone.0159461

4956033

Sania

Spiegelman

Rich-Edwards

: The contribution of preterm birth and intrauterine growth restriction to childhood undernutrition in Tanzania. Matern Child Nutr. 2015;11(4):618–30. 24720471

10.1111/mcn.12123

4300290

National Population Commission (NPC) [Nigeria] and ICF International: Nigeria Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA & NPC and ICF International;2014. Reference Source

Zhao

Gao

: Inappropriate Feeding Behavior: One of the Important Causes of Malnutrition in 6- to 36-Month-Old Children in Myanmar. Am J Trop Med Hyg. 2016;95(3):702–8. 27481057

10.4269/ajtmh.16-0019

5014282

10.5256/f1000research.25560.r63061

Reviewer response for version 1

Mongkolchati

Aroonsri

1 Referee 1ASEAN Institute for Health Development, Mahidol University, Nakhon Pathom, Thailand

Competing interests: No competing interests were disclosed.

14 5 2020

2020

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

recommendation

approve-with-reservations

The abstract was unclear of the result of this study, it should be addressed that after the authors control variable or adjust for confounding factors including mother height and socioeconomic factors. What were the factors have been found to be the determinants factors and this lead to the recommendation and conclusion to be more clear.

The statistic was used for data explanation should be more clear such as OR mean Cluded OR, COR, by bivariate whereas Adjusted OR, AOR, used for multivariate analysis.

The conclusion should consider one more limitation is that the small sample size of the data particularly on child stunning number on national WHO standard in comparing. As a result, the next research should be more explored.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Maternal and Child Health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Alkaff

Firas Farisi

Faculty of Medicine Universitas Airlangga, Indonesia

Competing interests: No competing interests were disclosed.

19 5 2020

Dear reviewer,

Thank you for the comments and suggestions to our manuscript.

1. The abstract was unclear of the result of this study, it should be addressed that after the authors control variable or adjust for confounding factors including mother height and socioeconomic factors. What were the factors have been found to be the determinants factors and this lead to the recommendation and conclusion to be more clear.

Response: We have edited the abstract section according to your suggestion.

2. The statistic was used for data explanation should be more clear such as OR mean Cluded OR, COR, by bivariate whereas Adjusted OR, AOR, used for multivariate analysis.

Response: We have changed the OR in the bivariate analysis to Crude OR and OR in multivariate analysis to Adjusted OR throughout the manuscript

3. The conclusion should consider one more limitation is that the small sample size of the data particularly on child stunning number on national WHO standard in comparing. As a result, the next research should be more explored

Response: We have added the small sample size particularly in the number of stunted children according to national Indonesian reference as one of the limitations in our study

10.5256/f1000research.25560.r63062

Reviewer response for version 1

Hermanussen

Michael

1 Referee https://orcid.org/0000-0003-4037-1597 1University of Kiel, Kiel, Germany

Competing interests: No competing interests were disclosed.

5 5 2020

2020

recommendation

approve-with-reservations

The authors aimed to compare Indonesian growth references for height, weight, and BMI with WHO standards. The authors conclude that the WHO standards over-diagnose stunting and underweight in the Musi sub-district.

This is an important study as it examines whether the globally used WHO growth charts are applicable also for infants and children of the Musi sub-district, Indonesia.

Yet, the manuscript needs clarification.

The authors do not clearly distinguish between the terms “standard” and “reference”:

Growth references are statistical summaries of anthropometry, conditioned (usually) on age and sex. References describe how children do grow.

Growth standards describe how children should grow. (Garza C, de Onis M. Rationale for developing a new international growth reference. Food Nutr Bull 2004;25(1 Suppl):S5-14.). This is an important distinction. The data presented in this study provide a growth “reference” for the children of the Musi sub-district as they describe how these children grow. They do not describe how these children might grow under different conditions.

The authors use the terms “stunting”, “wasting”, and “underweight”. These terms refer to body size, they do not describe the nutritional situation.

Underweight is defined as: weight for age < –2 standard deviations (SD) of the WHO Child Growth Standards median. Stunting is defined as height for age < –2 SD of the WHO Child Growth Standards median. Wasting is defined as weight for height < –2 SD of the WHO Child Growth Standards median ¹). The three terms relate to an internationally used “standard”, suggesting that this standard is also applicable to the Indonesian population. But this has been questioned. Healthy Indonesians are shorter and lighter than healthy white US citizens (who grow similar to what the WHO considers their growth standard). The difference in size between Indonesian and US Americans was the rational to develop national Indonesian growth references (Pulungan et al. 2018).

In addition, the authors use the term “undernutrition”. Undernutrition refers to food:

Undernutrition can be defined as "lack of proper nutrition, caused by not having enough food or not eating enough food containing substances necessary for growth and health" ( https://www.lexico.com/en/definition/undernutrition). Chronic undernutrition has an impact on body size as it results in poor growth, but being short (stunting) is not a synonym of mal- or undernutrition (Scheffler C et al. Stunting is not a synonym of malnutrition. Eur J Clin Nutr. 2019 May 29 ²). Short people may be short for other than nutritional reasons.

It is not clear whether the authors wanted to study size (length and weight), or the nutritional situation of the children of Musi. They start the manuscript with the words: “Undernutrition among children under five …”. Later it is written: “There are three indicators to measure nutritional imbalance that lead to undernutrition …” suggesting that the manuscript is on nutrition. But where is the data on food? The authors need to provide information on food, or at least on energy deposits in terms of skinfold thickness, arm circumferences etc., or in the case of mal- or undernutrition, show clinical signs of protein or calorie malnutrition, or signs of micronutrient deficiencies. This is not the case.

It is known to the reviewer that there is international confusion about the terms stunting and malnutrition. Calculating the portion of stunted children refers to the question of how many children are below height for age < –2 SD of the WHO Child Growth Standards median. This does not necessarily mean that this portion of children is also undernourished.

The manuscript needs major rethinking and re-evaluating of the measurements of height and weight. It is necessary to describe growth of the children of Musi, and to publish these data. The children of Musi are shorter and lighter than suggested by the WHO standard. But this does NOT mean that these children suffer from food shortage. It rather appears that the WHO standard is not applicable for these children, and thus does NOT indicate malnutrition of this child population. This needs to be stressed. The authors should carefully read some of the recent papers discussing the misinterpretation of stunting as a sign of undernutrition (Hermanussen et al. The impact of social identity and social dominance on the regulation of human growth. A viewpoint. Acta Paediatr. 2019 Aug 16 ³).

The tables show odds ratios. It is much more informative when data are presented as true values. The reader is not so much interested in what proportion of children ranges above or below a certain cut-off, but what are the mean values of height, weight, etc. in this child population.

Minor comments:

Correct the term “national standard”. What you mean is: “national reference”.

Correct the term “gender”. What you mean is probably “sex”.

Table 4 needs to be shortened, there is no need to show empty boxes. The same applies for table 6

Discussion: The authors write: “SGA is a result of poor maternal nutrition during pregnancy”. This is not quite true. Ample evidence obtained from European countries during periods of war and post-war starvation illustrates that even when pregnant women are severely undernourished, the newborn infants only suffer from minor decreases in body weight (Keys A, Brozek J, Henschel A, Mickelsen O, Longstreet Taylor H. The biology of human starvation. The University of Minnesota Press. Minneapolis. 1950.).

See various comments in the text.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Are all the source data underlying the results available to ensure full reproducibility?

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

child growth, pediatrics, endocrinology

References 1

: Country Profile Indicators Interpretation Guide. WHO .2010; Reference source

: Stunting is not a synonym of malnutrition. Eur J Clin Nutr .2020;74(3) : 10.1038/s41430-019-0439-4 377-386

31142828

10.1038/s41430-019-0439-4

: The impact of social identity and social dominance on the regulation of human growth: A viewpoint. Acta Paediatr .108(12) : 10.1111/apa.14970 2132-2134

31420898

10.1111/apa.14970

Alkaff

Firas Farisi

Faculty of Medicine Universitas Airlangga, Indonesia

Competing interests: No competing interests were disclosed.

19 5 2020

Dear reviewer,

Thank you for the comments and suggestions to our manuscript.

1. The authors do not clearly distinguish between the terms “standard” and “reference”

Response: We have distinguished the “standard” and “reference” in our revised manuscript. We use the term “reference” for Indonesian growth chart and use the term “standard” for WHO growth chart.

2. The authors use the terms “stunting”, “wasting”, and “underweight”. These terms refer to body size, they do not describe the nutritional situation.

Response: We do not refer stunting and underweight as nutritional status in our revised manuscript.

3. It is not clear whether the authors wanted to study size (length and weight), or the nutritional situation of the children of Musi.

Response: We have revised the manuscript and limited the aim of our study to body size (length and weight) of the Musi children, not about nutritional status because we do not have the data regarding food, energy deposits, or any clinical sign of undernutrition.

4. It is necessary to describe growth of the children of Musi, and to publish these data.

Response: Unfortunately, we do not have the growth record of children in Musi sub-district. The design of our study is cross-sectional, thus we only have one-time height and weight measurement of the Musi children. We have published the measurement data in online repository ( https://doi.org/10.6084/m9.figshare.12121938.v5 for population data and https://doi.org/10.6084/m9.figshare.12127425.v3 for determinants data)

5. The authors should carefully read some of the recent papers discussing the misinterpretation of stunting as a sign of undernutrition

Response: We have read the corresponding references, and we have made sure to not misinterpret stunting as the sign of undernutrition because the aim of our study is to compare the prevalence of body size using WHO growth standard and Indonesian growth reference.

6. The tables show odds ratios. It is much more informative when data are presented as true values. The reader is not so much interested in what proportion of children ranges above or below a certain cut-off, but what are the mean values of height, weight, etc. in this child population.

Response: We would like to give more informative data by presenting the true values of weight and height. However, since the children are not in the same age, we are not sure whether it is appropriate or not.

7. Correct the term “national standard”. What you mean is: “national reference”.

Correct the term “gender”. What you mean is probably “sex”.

Table 4 needs to be shortened, there is no need to show empty boxes. The same applies for table 6

Response: We have corrected the term “national standard” to “national reference” and term “gender” to “sex”. We also have shortened the table 4 and 6 by omitting the empty boxes.

8. Discussion: The authors write: “SGA is a result of poor maternal nutrition during pregnancy”. This is not quite true.

Response: We have removed the discussion regarding the relationship between SGA and poor maternal nutrition.

9. You might better conclude that "the WHO standard are not suitable for representing child growth in Musi sub-district".

Response: We have edited our conclusion according to your suggestion.